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INTRODUCTION

Disorders of sleep are among the most common problems seen by clinicians. More than one-half of adults experience at least intermittent sleep disturbances, and 50–70 million Americans suffer from a chronic sleep disturbance which can adversely affect daytime functioning as well as physical and mental health.

APPROACH TO THE PATIENT: Sleep Disorders

Pts may complain of (1) difficulty in initiating and maintaining sleep at night (insomnia); (2) excessive daytime sleepiness or tiredness; (3) unusual behaviors during sleep (parasomnias); or (4) circadian rhythm disorders associated with jet lag, shift work, and delayed sleep phase syndrome. Careful history of sleep habits and reports from the sleep partner (e.g., heavy snoring, falling asleep while driving) are a cornerstone of diagnosis. Pts with excessive sleepiness should be advised to avoid driving until effective therapy achieved. Completion of a day-by-day sleep-work-drug log for 1–2 weeks is often helpful. Work and sleep times (including daytime naps and nocturnal awakenings) as well as drug and alcohol use, including caffeine and hypnotics, should be noted each day. The physical examination may show a small airway, large tonsils, or a neurologic or medical disorder that contributes to the complaint. Objective sleep laboratory recording is necessary to evaluate specific disorders such as sleep apnea, periodic limb movements, and narcolepsy.

INSOMNIA

Insomnia is the complaint of poor sleep and usually presents as difficulty initiating or maintaining sleep. People with insomnia are dissatisfied with their sleep and feel it impairs their ability to function well. Affected individuals often experience fatigue, decreased mood, irritability, malaise, and cognitive impairment. Chronic insomnia, lasting >3 months, occurs in about 10% of adults. Acute or short-term insomnia affects over 30% of adults and is often precipitated by stressful life events. Most insomnia begins in adulthood, but many patients may be predisposed and report easily disturbed sleep predating the insomnia, suggesting that their sleep is lighter than usual.

All insomnias can be exacerbated and perpetuated by behaviors that are not conducive to initiating or maintaining sleep. Inadequate sleep hygiene is characterized by a behavior pattern prior to sleep, and/or a bedroom environment, that is not conducive to sleep. In preference to hypnotic medications, the pt should attempt to avoid stressful activities before bed, reserve the bedroom environment for sleeping, and maintain regular rising times.

Psychophysiologic Insomnia

These pts are preoccupied with a perceived inability to sleep adequately at night. Rigorous attention should be paid to sleep hygiene and correction of counterproductive, arousing behaviors before bedtime. Behavioral therapies are the treatment of choice.

Drugs and Medications

Caffeine is the most common pharmacologic cause of insomnia although a wide range of psychoactive drugs can interfere with sleep, including alcohol and nicotine. Numerous medications, including antidepressants, stimulants, and glucocorticoids, can produce insomnia. Severe rebound insomnia can result from the acute withdrawal of hypnotics, especially following ...

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